Multifaceted quality improvement initiatives improve rate of pediatric hand injury reduction.

BACKGROUND: Hand fractures account for a significant proportion of all fractures seen in pediatric emergency departments (ED). It is essential for initial interventions to be successful to avoid unnecessary repeat interventions/complications. We sought to assess whether quality improvement interventions could decrease the rate of repeat reductions by plastic surgeons in our tertiary centre. METHODS: We included patients ≤ 18 years of age who presented to ED with a hand injury from January 2014 to May 2019. Data were collected and presented over two plan-do-study-act cycles. The interventions comprised the dissemination of previous research identifying hand injuries requiring repeat reduction at our centre and commencement of a quality improvement initiative that coincided with hiring of a fellowship-trained pediatric hand surgeon and the implementation of an electronic medical record. In the second plan-do-study-act cycle, we implemented formal educational workshops for ED physicians and a standardized flowsheet in our electronic medical record to track patients with hand injuries. RESULTS: We identified 272 hand injuries (136 in cycle 1, 136 in cycle 2) from January 2014 to May 2019. As a result of the implemented quality improvement initiatives, the proportion of hand injuries requiring repeat reduction decreased from 8.7% (n = 8) to 3.0% (n = 2) during cycle 1. This improvement was sustained during the 17-month-long (November 2017-May 2019) second cycle (3.0%, n = 6). CONCLUSION: This study highlights the importance of multifaceted interventions to achieve improved patient care, specifically the potential impact of specialized physicians, informal feedback and education, formal teaching workshops, and electronic medical records.

RéSUMé: CONTEXTE: Les fractures de la main représentent une proportion importante de toutes les fractures vues dans les services d'urgence pédiatriques. Il est essentiel que les interventions initiales réussissent afin d'éviter des interventions/complications répétées inutiles. Nous avons cherché à évaluer si les interventions d'amélioration de la qualité pouvaient réduire le taux de réductions répétées par les chirurgiens plasticiens dans notre centre tertiaire. MéTHODES: Nous avons inclus les patients ≤ 18 ans qui se sont présentés aux urgences avec une blessure à la main entre janvier 2014 et mai 2019. Les données ont été recueillies et présentées au cours de deux cycles planifier-faire-étudier-agir. Les interventions comprenaient la diffusion de recherches antérieures identifiant les blessures à la main nécessitant une réduction répétée dans notre centre et le lancement d'une initiative d'amélioration de la qualité qui a coïncidé avec l'embauche d'un chirurgien de la main pédiatrique formé en bourse et la mise en œuvre d'un dossier médical électronique. Au cours du deuxième cycle planifier-faire-étudier-agir, nous avons mis en place des ateliers éducatifs formels pour les médecins des urgences et une feuille de route standardisée dans notre dossier médical électronique pour suivre les patients souffrant de blessures aux mains. RéSULTATS: Nous avons identifié 272 blessures à la main (136 au cycle 1, 136 au cycle 2) entre janvier 2014 et mai 2019. Grâce aux initiatives d'amélioration de la qualité mises en œuvre, la proportion de blessures à la main nécessitant une réduction répétée a diminué de 8,7% (n = 8) à 3,0% (n = 2) au cours du cycle 1. Cette amélioration s'est maintenue tout au long du deuxième cycle de 17 mois (novembre 2017-mai 2019) (3,0%, n = 6). CONCLUSION: Cette étude souligne l'importance d'interventions multiformes pour parvenir à améliorer les soins aux patients, en particulier l'impact potentiel des médecins spécialisés, de la rétroaction et de l'éducation informels, des ateliers d'enseignement formels et des dossiers médicaux électroniques.

Predictors of Adverse Pregnancy Outcomes in Pregnant Women Living with Obesity: A Systematic Review.

Obesity is a well-recognized risk factor for pregnancy complications. Most studies to date are in large cohorts, with results presented in a way that assumes all women living with obesity are at equal risk. This study investigates which women living with obesity are at higher risk of specific pregnancy complications. A systematic search of MEDLINE and Embase identified 7894 prospective or retrospective cohort studies exploring predictors of adverse outcomes among pregnant women living with obesity. Following screening, 61 studies were deemed eligible. Studies were selected if the effects of exposure to any predictor amongst pregnant women living with obesity could be collected. Maternal characteristics assessed for association with adverse outcomes included maternal age, race/ethnicity, maternal height, mode of conception, complement activation factors, and history of various comorbidities/procedures. Gestational diabetes mellitus was the most studied outcome (n = 32), followed by preterm birth (n = 29), preeclampsia (n = 27), low birthweight infants (n = 20), small for gestational age newborns (n = 12), and stillbirth (n = 7). This review identified important characteristics that should be considered during the screening and follow-up sessions of pregnant women living with obesity, including pre-existing type 1 diabetes, maternal age < 20 years or ≥35 years, non-White ethnicity, abdominal adiposity obesity, and history of bariatric surgery.

Hands-On Workshops Improve Emergency Department Physicians' Self-Reported Understanding of Pediatric Hand Injuries.

OBJECTIVES: The aims of this study were to assess emergency department (ED) physician perception of hand injuries and improve their understanding and confidence in treating these injuries. METHODS: Combined didactic and hands-on workshops for ED physicians were developed and run by a team of medical students, plastic surgeons, and ED physicians. The workshops consisted of a short review by a hand surgeon followed by hands-on sessions involving radiograph assessment, administration of local anesthetic, closed reduction, and splinting. Two sessions, 6 months apart, were provided. The workshops were evaluated using preworkshop and postworkshop questionnaires to assess the following domains: confidence and competence in treating hand injuries, knowledge of basic hand injury care, and feedback on the intervention itself. RESULTS: Fifty physicians participated in the workshops. After the workshops, physician recognition of hand fracture reduction as a critical skill increased. Self-efficacy ratings of fracture assessment, administration of local anesthetic, performing a reduction, and applying postreduction immobilization increased. Median scores on knowledge-testing questions also increased postintervention from 73.3% (95% confidence interval, 70.2-78.5) to 86.7% (95% confidence interval, 79.3-86.2) (P < 0.05). Finally, physicians reported that they found the intervention educational, useful, and important, and approximately 90% of participants indicated they intended to change their practice based on this intervention. CONCLUSIONS: Knowledge sharing between specialists and generalists through combined didactic and hands-on workshops is an effective and well-received method of refining physician knowledge and increasing confidence in treating subspecialty-specific clinical presentations.